Provider Demographics
NPI:1053832717
Name:MITCHELL-FULLWOOD, TISA L (FNP)
Entity Type:Individual
Prefix:
First Name:TISA
Middle Name:L
Last Name:MITCHELL-FULLWOOD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2994 KILDAIRE FARM RD
Mailing Address - Street 2:
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-9614
Mailing Address - Country:US
Mailing Address - Phone:919-387-1075
Mailing Address - Fax:
Practice Address - Street 1:2994 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-9614
Practice Address - Country:US
Practice Address - Phone:919-387-1075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010016363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily